| VAERS ID: |
1074955 (history) |
| Form: |
Version 2.0 |
| Age: |
82.0 |
| Sex: |
Male |
| Location: |
Oklahoma |
| Vaccinated: | 2021-02-13 |
| Onset: | 2021-02-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-03-05 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
030M20A / 1 |
RA / IM |
Administered by: Military Purchased by: ? Symptoms: Death,
Fall,
Feeling abnormal,
Head injury,
Muscular weakness,
Respiratory arrest,
Resuscitation SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Hypersensitivity (broad), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-14
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Metroprolol, zetia, Multag for AFIB, metformin,lisinopril, Immodium, Atorvastatin, was on a blood thinner but stopped 1/25/21 Current Illness: DX with Covid -19 on Jan 2, 2021, had surgery on Jan 28th, 2021 to remove scar tissue between the bladder and prostate. Preexisting Conditions: Afib, diabetes, hypertention, blood clotting disorder Allergies: NKDA Diagnostic Lab Data: none CDC Split Type:
Write-up: at midnight client got up to go to the bathroom. His legs became weak and he fell and hit his head on the wall. He called for his wife and said he didn''t feel right. He denied any pain. She called EMSA and he stopped breathing while she was waiting on them. She gave him CPR with instructions from the dispatcher. He was pronounced dead at 1:30am. She has tried to call the clinic 3 times and left messages and no one has called her back, Her PCP told her this needed to be reported . |